[Article] Evaluation of real-time data obtained from gravimetric preparation…

I am currently reading an article on the use of gravimetrics in the preparation of hazardous CSPs published in the Journal of Clinical Pharmacy and Therapeutics.*

The article addresses data collected from a large-scale, retrospective analysis of medication errors identified during the preparation of antineoplastic drugs, aka chemotherapy. The paper looks at 759 060 doses prepared in 10 pharmacy services in five European countries (Austria, Czech Republic, Denmark, Germany, and Switzerland) between July 2011 and October 2015. While the sheer number of CSPs made over that period of time isn’t impressive, the fact that they’re all chemotherapy is. I believe this is the first article of its kind. I can’t think of another article that looks at the use of an IV workflow management system across such a large number of facilities, much less the use of gravimetrics during the compounding of sterile hazardous drugs.

The authors of the paper do a good job of: (1) addressing the use of gravimetrics versus image-assisted volumetrics, (2) covering the weaknesses of using syringes to measure small volumes (take a look at FIGURE 2 Tolerances of 1- and 5-mL syringes), and presenting a solid case for why gravimetrics is important for preparing hazardous CSPs. It also has some good images and tables, which I plan to refer to in future presentation.

In a nutshell “[e]rrors were… identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection“. I find that this is the key benefit of using a system with gravimetrics, i.e. the accuracy of the dose doesn’t rely on human inspection. Overall, the gravimetric system caught errors in 7.89% of the 759 060 antineoplastic doses prepared. This percentage is consistent with other studies looking at CSP error rates.

A total of 13 831 errors for doses that deviated by more than 10% were caught by the system. That may not sound like a lot, but it can be, depending on the situation. Worse yet, 4 467 errors were off by 20% or more. Regardless of the situation, a 20% deviation in a dose is unacceptable. The significance, of course, is that a deviation this large could result in unintended toxicity or under treatment, depending on the direction of the error, i.e. 80% – 120% of the prescribed dose.

The article concludes that the “Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment.” I agree in principle with the sentiment, but believe that the authors overstate the significance of the gravimetric system while understating the importance of secondary checks. By stating that the system “prevented dosing errors which would not have been recognized with traditional methods” they are assuming that all errors would have made it past a pharmacist or other secondary verification method. It’s possible — maybe even likely — that some of the errors would have made their way past a secondary check, but not all. In many cases, chemotherapy preparations go through several step-checks during the compounding process. Typically, one of those step-checks is verifying the dose — volume in the syringe — prior to injecting it into the final container. Errors are often discovered at this point in the process. With that said, the author’s overzealous conclusion shouldn’t take away from the importance of gravimetrics in preparing CSPs.

Do yourself a favor and go get a copy of the article. It’s worth a few minutes of your time.

The online article is here.

A PDF copy can be downloaded here.

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Notes:

The system used in all the pharmacies was BD Cato.

BD funded the project. While this can raise some red flags, I don’t think it’s enough to disqualify the data. Other companies, like Baxter, sponsor half of the sessions on compounding safety at ASHP Midyear. I for one am happy they do it. Support from companies like BD and Baxter go a long way in bringing important topics like compounding safety to the masses. So, focus on the use of gravimetrics, not on the company that sponsored the paper.

*Terkola R, Czejka M, Bérubé J. Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study. J Clin Pharm Ther. 2017;00:1–8. https://doi/org/10.1111/jcpt.12529

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Laying the foundation for your technology implementation team

I’ve been thinking a lot lately about the right way to go about putting new technology into a pharmacy. Making the decision to add technology doesn’t mean running out and purchasing a million-dollar piece of equipment and shoving it in a corner. It’s much more complicated than that. You must first lay the foundation for the work to be done.

Here are some things that I think should be considered before putting new technology in the pharmacy:

Give everyone fair warning of what you plan to do. No one likes to be surprised and people fear change. The best policy is to give people plenty of warning before making a change, which will allow them to get used to the idea. This will go a long way in gaining support for the project. Being aware of what’s coming is always preferable to being surprised by what has already been done.

Gauge user beliefs and feeling. It’s best to take the temperature of pharmacy personnel prior to getting started. Is it going to be an uphill battle? Are the pharmacists and technicians open to the idea of implementing new technology? Is the pharmacy morale where it should be? Does your department fear change?

The success of the implementation depends heavily on how well the department is warned and prepared for the change. People often see technology as a threat to control over their work environment, resulting in pushback. Helping staff understand what it is you hope to accomplish, how it will help them, and offering opportunities for staff to become vested in the project can go a long way in ensuring a successful implementation.

Get support/buy-in for the project. Support for any project is a must. Recruit from the top of the organization to the bottom. Failure to do so may result in a failure to launch.  Whenever possible it is best to have support from the highest level of the organization, executive sponsor or someone from the board if you have one.  Influence matters. And don’t forget to involve all departments that will be impacted by the change, including nurses and physicians when appropriate.

Create a buzz. Create some excitement. Don’t act like the project is required, but rather a choice that’s going to make things better.  This is the power of advertising. We fall for it all the time, from cars to smartphones.

User involvement and participation. When individuals believe that the implementation of technology is relevant, they are much more likely to have a positive attitude toward the project. The best way to get individuals to believe in the technology is to get them involved and allow them to participate in all phases of the project. “Increasing user participation … enhances post-development user involvement and attitude”.(1)

Involve as many people as possible as often as possible. When people are involved, it gives them a sense of ownership, making them vested in the project’s success. It also helps deal with negative vibes that may come from others.

Volunteers only. It is important that all participants be volunteers as mandated participation has been shown to be ineffective and potentially detrimental to the success of this type of project. (2)

Champions. Champions are the people that go above and beyond the general participant. Champions believe in the technology and the benefits it will provide. They can often have a contagious zeal about the project, and are sometimes referred to as “evangelists”, or in extreme cases “zealots”. Whatever you call them, you need them. When it comes to implementing new technology in the pharmacy, champions can be your best source of support and are often useful in putting a spotlight on the project in a positive way while swaying negative feelings about the project. 

Finding Champions shouldn’t be too difficult. There are usually early adopters in every group. They will often present themselves while taking the initiative to learn more about the project without being asked.

Develop rules for participation. This is really quite simple. It is important that the rules for participation be laid out well in advance, and that each member of the team signs off on them. There should be no surprises for what’s expected from participants once the project is underway. The following rules are examples:

  • Be willing and able to engage in the project
  • Be willing to be positive about the project
  • Be willing to work with others to advance the project
  • Be willing to commit to attending meetings
  • Be willing to commit to handling extra work, even if it means staying late or doing some reading at home in the evenings or on the weekends. I understand that no one wants to put in a bunch of unpaid overtime on these projects. However, on occasion, a little extra work needs may need to be done to keep things moving forward. One should enter into participation with the understanding that this could happen.
  • Be willing be engage in every aspect of the project, not only the items that are assigned. It is vitally important that each participant has at least a basic understanding of the overall scope of the project and what each member of the team is assigned to do. Things happen. People get sick, quit their jobs, move to another state, and so on. Such unforeseen events should not completely derail the project timeline or goals. 

Sway the naysayers. Every project has its opposition. As the saying goes, you can’t please everyone all the time. Unfortunately, naysayers tend to be the most vocal personalities in any group. They’re not afraid to say what’s on their mind; whether positive or negative. The downside is that outwardly negative comments about a project have a way of spreading like wildfire. They’re caustic and often seep into the minds of even the staunchest supporter without warning. And once planted, negative thoughts grow like a cancer.

Naysayers and their negative comments have their place. They often point out things that others fail to see, helping avoid pitfalls along the way. The trick is to use the information to your advantage and allow naysayers to offer their thoughts in an environment that won’t bring down the rest of the pharmacy. Give them space to vent, and then do your best to use the information to flip them. If you can show the naysayers in the group that you’re willing to listen to them and take their concerns seriously, you may be able to get them on your side. That’s a huge victory for any project. On the other hand, never force change on a naysayer. Forcing change or mandating them to join your side rarely works. It’s like dealing with a donkey, the harder you pull, the harder they resist.

Build a team with high potential for success. According to Harvard Business Review’s (HBR’s) 10 must Reads On Emotional Intelligence (3), the source of great success lies with teams that can achieve high levels of participation, cooperation, and collaboration among members.

Team members must be chosen carefully and meet three basic conditions:

  1. Mutual trust of one another
  2. Have a sense of group identity – a feeling that they belong and the project is worthwhile
  3. Have a sense of group efficiency – belief that the team can perform well and that the group is better than the individual members.

Collectively, HBR refers to this as the groups “emotional intelligence” (EI). And while the knowledge and experience among group members is important, EI may be more important still. Keep this in mind when you begin building the project team.

Chose a project leader. Being “the leader” is a burden that many well-qualified individuals shy away from. With that said, someone has to be in charge. Someone has to be given authority over the group. Someone has to be willing to make the tough decisions and hold people accountable.

Not everyone is cut out to be a leader. I am of the opinion that leaders are born, not made. You either have it or you don’t. I know because I’ve tried many times to lead and failed. It wasn’t for lack of knowledge or desire, but rather a lack of natural leadership and charisma. On the flipside, I’ve been around many people that just have “it”; “it” being a knack for getting people to follow them and do what they say, i.e. they’re natural born leaders.

What distinguishes good leaders from great leaders is “a group of five skills that enable the best leaders to maximize their own and their followers’ performance.” (3)

The five skills are:

  • Empathy
  • Motivation
  • Self-regulation – controlling negative impulses
  • Self-awareness – knowing strengths and weaknesses
  • Social skill – being able to build a rapport with others to get desired results

Find a project manager. As ridiculous as this may sound, the project manager is an often overlooked position when discussing project teams. Let me go on record now as saying that a good project manager is absolutely vital to the success of any project; arguably the most vital consideration to the success of a project.

It is the job of the project manager to manage all aspects of the project, including the scope, the timeline, the cost, the quality, and the people. They apply their knowledge, skills, tools, and techniques to help projects be successful.

The role of the project manager is that of an enabler. Her job is to help the team get the work completed, to “run interference” for them, to get scarce resources that they need, and to buffer them from outside forces that would disrupt the work.”(4)

Things to consider when selecting a project manager:

  1. The person must have leadership qualities, have good self-management and time management skills, and be a taskmaster.
  2. The project manager cannot serve two masters. Individuals that serve as a project manager must not be required to do any of the actual work in the project. According to Lewis (4), “as team sizes increase, it becomes impossible to work and manage both[the work and the team], because you are constantly being pulled away from the work by the needs of your team members”. Having project managers attempt to manage the project in addition to working on the project is a recipe for disaster.
  3. The person must have a proven track record. We all know people that can’t manage the paper piles in their office much less a multi-faceted project requiring meticulous attention to detail.

I encourage everyone involved in a large project to read a book or two on project management. Being a project manager is not as easy as it sounds and should be given the respect it deserves.

That’s it. Piece of cake. Go forth and build your implementation team.

  • Vaughan PJ. Internal Report of Information Technology Services. University of Colorado at Boulder. 2000.
  • Hunton, J.E. and Beeler, J.D., Effects of User Participation in Systems Development: A Longitudinal Field Experiment. MIS Quarterly, 21(4), 1997, pp. 359-388.
  • Hbrʼs 10 Must Reads On Emotional Intelligence. 1st ed. Boston (Massachusetts): Harvard Business Review Press, 2015. Print.
  • Lewis, James P. Fundamentals Of Project Management. New York: American Management Association, 2007. Print

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Time to revisit gravimetrics in the IV room 

Summary: if you’re preparing compounded sterile preparations (CSPs) in a pharmacy IV room, you should be using gravimetric analysis to determine the appropriate dose/volume.

Pharmacy practice is easy. Our job is to provide the right drug, at the right dose, to the right patient in the safest, most efficient, cost-effective manner possible. Simple.

Currently, the only method for ensuring that the correct drug is used during sterile compounding is barcode scanning. The future may hold other methods — I’ve read promising things about real-time solution concentration and drug identification using Raman spectroscopy — but for now, barcode scanning is it.

There are three basic methods for ensuring the correct dose/volume: traditional volumetrics using the pull-back method or using a pharmacist step-check process; photo-assisted volumetrics where the pharmacist views a photo of the drug drawn up in the syringe (1); and gravimetrics.(2)

Figure 1 from Terkola et al. J Clin Pharm Ther. 2017

The Volumetric method is limited by human error. In a situation where the pharmacy utilizes the pull-back method, there’s nothing to prevent a wrong dose from accidentally being injected into a bag only to have the technician pull the empty syringe back to the correct volume. The pull-back method of IV preparation is universally panned by organizations like ASHP and ISMP. Any pharmacy still using the pull-back method to prepare CSPs should be considered criminally reckless as they are endangering the lives of their patients every time they make an IV. It is unconscionable to be using the pull-back method for IV preparation in this day and age.(3)

Using either a step-check process or photo-assisted volumetrics is significantly better than the pull-back method, but not without their pitfalls. I’ve seen errors resulting from both methods where the technician pulled the wrong dose and the pharmacist verified it. It is unclear how this happens. It may result from checking bias, simple “slips”, or even laziness on the part of the pharmacist. It’s difficult to know for certain.

Gravimetric analysis utilizes the specific gravity of a solution to quantitatively determine the analyte, i.e. the drug found in the solution. In the case of an i.v. preparation, the method can be used to determine the accuracy of a dose drawn into a syringe, removed from a vial, injected into an i.v. bag, and so on. The assumption is that if you know the weight of an object – syringe, i.v. bag, a vial of medication, etc – before and after adding or removing a substance, then you know exactly how much drug was added or removed.

Gravimetrics acts as a forcing function, i.e. you can’t continue the compounding process until you have the correct weight. It’s also incredibly accurate. The only thing I’m uncertain about at this moment is how low the weight can be and still be accurate. This is important as small volumes in small syringes can be problematic.

Overall, syringes as a measuring device are accurate, but variable.(4) Tolerances for sterile graduated plastic single-use hypodermic syringes are defined by the International Organization for Standardization (ISO), specifically ISO 7886-1. ISO standards vary by syringe size and volume of fluid drawn and expelled. The commonly accepted definition for an accurate disposable syringe below 5 mL nominal capacity is +/-­ 5% when measuring volumes at or above 50% nominal volume. Accuracy increases slightly to +/- 4% when measuring volumes at or above 50% nominal volume for syringes greater than 5mL nominal capacity.

Figure 2 from Terkola et al. J Clin Pharm Ther. 2017

There are several semi-automated IV workflow management systems available today. They range from low-end, lightweight systems to high-end, feature robust systems. Pick your poison, as they say. However, I encourage anyone looking for one of these systems to give serious consideration to those that offers a fully integrated scale, i.e. gravimetrics. Doing otherwise could potentially be tragic.

Left to right: i.v.SOFT from Omnicell, BD Cato from BD, DoseEdge from Baxter. Image Source: Jerry Fahrni, Pharm.D.

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  1. The photo can be viewed before or after the drug is shot into the final container, depending on the workflow. Obviously, viewing a photo of a syringe containing drug after the CSP has been made has its limitations.
  2. The image does a good job of showing the difference between volumetric and gravimetric preparation. Source: Terkola R, Czejka M, Bérubé J. Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study. Journal of Clinical Pharmacy and Therapeutics. 2017. doi:10.1111/jcpt.12529.
  3. I’m of the opinion that state boards of pharmacy should begin fining pharmacies that still use the pull-back method for IV prep. Administrators should be held professionally and personally responsible for allowing the method to continue. It simply shouldn’t be allowed. It’s dangerous, reckless, and lazy.
  4. Poppe L, Savage S, Eckel S. Assessment of final product dosing accuracy when using volumetric technique in the preparation of chemotherapy. Journal of Oncology Pharmacy Practice. 2016;22(1):3-9. doi:10.1177/1078155214549489.

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Compounding Today: state board of pharmacy concerns with USP <800>

Each Friday the CompoundingToday Newsletter faithfully appears in my inbox. The newsletter features commentary by Lloyd V. Allen, Jr., Ph.D., RPh, Editor-in-Chief of the International Journal of Pharmaceutical Compounding. Dr. Allen is a legend in the pharmacy compounding world for both sterile and non-sterile products. He was someone that I looked up to during my early years as a pharmacist; still do, as a matter of fact.

Long before USP <795> and <797> existed, he was preaching the gospel of proper compounding technique and the need for specialized training. Truly a visionary man ahead of his time. I hope to meet him in person someday.

So it should come as no surprise that I take seriously every thought and opinion he has. In last week’s Compounding Newsletter, Allen tackled an interesting topic with some thoughtful commentary.

From the newsletter:

Numerous state boards of pharmacy have concerns about United States Pharmacopeia (USP) Chapter <800> Hazardous Drugs-Handling in Healthcare Settings.

– The official chapter goes beyond the walls of the pharmacy and into healthcare settings, including physician offices, clinics, hospitals, treatment centers, etc. where state boards of pharmacy don’t generally have authority for enforcement.

– The requirements of <800> are very strict and extremely costly; many smaller pharmacies will no longer be able to serve their patients who depend upon compounded medications so they will simply cease compounding patient-specific medications, including some hospitals.

– There are some aspects of <800> that should be the burden of manufacturers and distributors, not pharmacies. As an example, no package should be delivered to a pharmacy contaminated with hazardous drug (HD) contents on the package surfaces that exposes pharmacy personnel upon opening. This is the responsibility of the manufacturer and distributor…

– Many of the requirements of <800> are based upon “opinion” and not necessarily upon science as demonstrated by documented, prospective studies.

It’s interesting to note that USP <800> extends into all areas where HD’s may be used, including physician offices. Where will that oversight come from? Will pharmacies be held accountable?

Dr. Allen has always been an advocate for “the little guy” and been cognizant of the balance between practical regulation and overbearing regulation. This is clear in his assessment of many areas within USP <800>. While I don’t necessarily agree with everything he says, I believe that his commitment to pharmacy practice and patient care deserve our attention. As he states, it is possible that the new regulation will simply be too much for some, resulting in the closure of compounding facilities. The greater concern, at least for me, is what impact the new requirements will have on hospital pharmacies where budgets drive change. A shift in budgetary requirements will likely mean that important projects will be postponed or canceled in favor of meeting USP <800>. The untoward consequences could be felt for years to come.(2)

Dr. Allen’s zinger about the lack of science is understandable and shared by many, but I don’t believe that prospective studies are always necessary to begin a process. For example, would you really want a 10-year pilot study showing that healthcare workers in the U.S. exposed to HDs are 10 times more likely to die of cancer than those that don’t before implementing these guidelines?(1) No, of course not. As I’ve said many times before, some fields – clean room procedure and pharmacy technology, for example – cannot be studied and scrutinized in the same manner as therapeutics. We simply can’t wait 5-10 years to change operational practices. With that said, USP <800> probably goes too far too fast in certain aspects of the regulation. Only time will tell whether the new guidelines will have the same impact as USP <797> did back when they were introduced.

Dr. Allen goes on to state: “As state boards of pharmacy have options other than accepting USP <800> in its entirety… The purpose of this document is to simply provide a resource from which state boards of pharmacy can “pick and choose” items to include for their respective state.” While this may be true, it is one area where I disagree with Allen. Giving each state the ability to “pick and choose” how to implement and use USP <800> makes things incredibly difficult. California, for example, has made a complete mess out of their new regulations. Other states will do the same, creating chaos. In Allen’s scenario, moving ten feet across a state boundary could mean following a completely different set of rules. How does that make sense? I recommend developing USP <800> to a point that everyone can live with and use it. Period.

I encourage you to read through the most recent issue of the CompoundingToday Newsletter. I also recommend that you “click subscribe” as well. The information is good and thought-provoking.

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  • This is a fictitious example.
  • As my friend and colleague, Ray Vrabel likes to say, the clean room is “clean, but deadly”, referring to the fact that we spend all our money on regulation and virtually nothing on technology to improve safety.

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Automated detection of LASA medication errors

 

Look-alike/sound-alike (LASA) medications – also referred to as sound-alike, look-alike drugs (SALAD) (1) — have been a thorn in the side of healthcare professionals for as long as I’ve been a pharmacist.

Many solutions to the LASA problem have been proposed, including Tall Man Lettering (2), physical separation of look-alike drugs, printing of both brand and generic names on packaging and storage bins, use of colorful warning labels, and so on and so forth. The problem with all these solutions is that they involve humans. Working in acute care pharmacy has taught me over and over again that as long as humans are involved there will be errors.

Technologies can help. Automated carousel technology and robotics can help manage physical separation of the medications and eliminate visual bias generated by human eyes. Bar-code scanning can certainly aid in identifying medications correctly. Bar-codes don’t care that medications have similar names, they’re either right or wrong.

In a recent article by Rash-Foanio (3) et al. the authors use an algorithm to flag potential errors from LASA drugs when an order meets the following criteria:

  1. a medication order is not justified by a diagnosis documented in the patient’s record
  2. another medication whose orthographic similarity to the index drug exceeds a specified threshold exists
  3. the latter drug has an indication that matches an active documented diagnosis.

In the study the authors perform a retrospective analysis to identify errors that involved cyclosporine and cycloserine. The algorithm wasn’t perfect. Sixteen orders involving unique patients were found. Additional chart review of the errors discovered that 5 (31%) identified by the algorithm did not involve a medication error, i.e. the intended medication was correct. However, the algorithm correctly identified 11 (69%) LASA errors.

While it may not catch all LASA errors, it seems that EHRs should give AI and some deep learning serious considerations for items like this. Preemptively catching greater than 50% of LASA errors is better than catching zero. (5)

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  1. I came out of pharmacy school having learned the phrase “sound-alike, look-alike drugs” (SALAD). At some point it changed to look-alike/sound-alike (LASA). Not sure when, how, or why it changed, but them’s the breaks. Just go with it. Adapt or die, I suppose.
  2. I’ve never been a fan of tall-man lettering, and it isn’t even clear that it works to reduce errors.
  3. Rash-Foanio, Christine et al. “Automated Detection Of Look-Alike/Sound-Alike Medication Errors”. American Journal of Health-System Pharmacy7 (2017): 521-527. Web.
  4. Kondrak, Grzegorz, and Bonnie Dorr. “Automatic Identification Of Confusable Drug Names”. Artificial Intelligence in Medicine1 (2006): 29-42. Web. 28 Apr. 2017.
  5. Honestly, one of the simplest things we can do is force providers to select an indication when ordering LASA medications. That simple act has the potential to significantly reduce these errors.

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So I bought a Chromebook 

I’ve had a Chromebook for a while now. My wonderful wife got me the original Samsung Chromebook in early 2012 for my birthday, I think. The device has been a trusted couch companion ever since. I mostly use it to check email, watch YouTube videos, surf the internet, and so on. It has a small 11.6-inch screen and limited horsepower. The little guy was never meant to be used for any heavy lifting. I have a Windows 10 laptop for that.

A few months ago I got the itch to buy another machine. I would dearly love to have a Microsoft Surface Book or Lenovo ThinkPad Yoga. It is my personal belief that these are the two best machines on the market today. With that said, they’re expensive, and honestly, they’re overkill for what I do. I mostly do research on projects and create content, typically in the form of documents, spreadsheet, blog post, and presentations. My presentations can get pretty gnarly in terms of size and media content, but still, a Core-i7 with 16 GB of RAM just feels extreme for my needs. So why not a Chromebook? Yeah, why not, indeed.

So I set about making a list of things that I wanted from a Chromebook. Two of the most important items were:

  1. A 14-inch or larger screen. I’ve historically preferred smaller screens, especially between 12-13-inch. However, I’ve been thinking about trying a laptop with a larger screen for a while. And what better way to do it than with an inexpensive Chromebook?
  2. Long battery life. This is a no-brainer.

After the two items above, my list grew to include:

  • Under $500. Let’s face it, it’s hard to spend more than $500 on a Chromebook knowing that for around $700 I could get a really nice Windows 10 tablet.
  • Good keyboard. I do a lot of typing, so whatever machine I buy has to have a good keyboard.
  • Backlit keyboard. This seems to be a polarizing topic. I feel that it’s important, at least for me. I do a lot of early morning and late night surfing. I don’t always have a great light source, so having a backlit keyboard is nice.
  • At least 32 GB of local storage. Chromebooks are notoriously bad when it comes to local storage. I can’t see buying something with less than 32 GB of storage.
  • Touchscreen. Once you’ve used a laptop with a touchscreen, it’s hard to go back. It would be especially handy should my Chromebook support Android apps.
  • Expandable storage.  Any acceptable way to increase storage, not only an SD card slot. As long as there’s a free USB port, I’m good.

I was pretty excited when I saw the Samsung Chromebook Plus and the Asus Chromebook Flip C302 hit the market. Both have touchscreens and offer a 2-in-1 configuration. The Samsung pulled at me hard, but besides having only a 12.3-inch screen, it was also missing a backlit keyboard, and was at the very edge of my $500 mark. For reasons unknown, the Flip C302 doesn’t capture my interest. It has a backlit keyboard and better storage options than the Samsung, but meh.

After reading a lot of reviews and looking through countless “best Chromebooks of 2017” lists, I came to the conclusion that a 14-inch Chromebook with a backlit keyboard just wasn’t in the cards. I ended up going with the Acer Chromebook 14, in gold. I got a great price at Amazon.  It lacks almost everything on my list, but it does have a 14-inch screen and remarkable battery life.

The Acer Chromebook 14 has an all metal build, a good but not great 14-inch screen, a good keyboard, solid battery life, and it’s snappy. It’s also easy on the eyes. When up close and personal, no one would mistake it for a $2000 premium laptop, but it’s still a handsome device.

I’ve been using my new Chromebook for about two weeks. So far things have been pretty good, but I definitely have some minor quibbles.

There are several keys missing from the Chromebook keyboard. For example, there are no dedicated ‘delete’, ‘home’ or ‘end’ keys. I’m a content creator, so I use those keys a lot. Fortunately, there are Chromebook equivalents, like ‘alt’ + ‘backspace’ = ‘delete’, or ‘search’ + ‘right arrow’ = end of line, etc. I keep a copy of the Chromebook shortcuts handy. Fortunately, you can also remap certain keys. For example, remapping the relatively useless ‘search’ key to CAPS LOCK. Seriously, who doesn’t need to type IN ALL CAPS ONCE IN A WHILE. I’m slowly starting to get used to the keyboard function and layout, but it hasn’t been a smooth transition.

The “right-click” on Chromebooks is not a right-click, at all. In fact, the right click is a two finger tap. This tiny difference is giving me fits. Who knew that I right-clicked so often?

Everything being in a browser tab will take some getting used to. I’ve been using the Windows OS for more than 20 years. I’m comfortable with a bunch of little windows on my screen, not just a single browser with multiple tabs. Changing some of the web apps to “open as window” has helped. I did this for Google Docs and Google Music. It has nothing to do with functionality, but it makes my screen more familiar, which ultimately makes me feel better. Don’t judge me!

I’ve always considered myself a heavy user of web-based apps. I spend most of my time in the Chrome browser flipping through websites, reading literature, using Gmail/Google Calendar/Google Keep/Google+, using the web versions of Twitter and Facebook, and so on. Working in “the web” is great, except when it’s not. There are some web applications that simply don’t measure up to their desktop counterparts.

Here are some examples:

Evernote – I’ve been trying to extricate myself from Evernote for quite some time, but I haven’t found a suitable replacement. The application is too valuable to the way I work, so for now it stays. Unfortunately, the Windows 10 desktop version of Evernote is significantly better than the web version. Converting back to the “old” version of the web app has helped, but it’s still not the same.

Microsoft Office vs. Google Docs – As a content creator, I use Microsoft Office 365, a lot. I create documents, blog posts, spreadsheets with graphs, and presentations. For the most part, replacing the web versions of Word with Google Docs hasn’t been an issue. For example, I’m using the online version of Office 365, Word specifically, to write this post. I used Google Docs for Sunday’s post. Both worked fine. I prefer Word, but Docs is usable. Replacing Excel with Sheets is ok, but I’m struggling with graphs. Google Slides is another story. Slides is way behind Microsoft PowerPoint in my opinion. The desktop version of PowerPoint is much better than the web app, and the web app is still much better than Google Slide. This might be a deal-breaker for me. I’ve found a few workarounds for PowerPoint Online, but honestly, I don’t like workarounds. It’s not all terrible. I do like the auto-save functionality when using Google Docs or Office 365 Online. Every change I make is automatically saved. No more losing 20 minutes worth of work because I was too lazy to hit ‘CTRL S’.

Zotero – I’m a pharmacist. I read literature. I’m also a digital pack rat. I collect and store lots and lots of journal articles, whitepapers, presentations, and so on. I refer to them when composing blogs or papers and when building presentations. Using a reference management tool is a must. In my case, that reference manager is Zotero. I collect all my references in Zotero. It pulls complete bibliographies from digital object identifiers (doi’s), allows me to link to full article PDFs stored in OneDrive, and gives me the option to attach notes to each entry. New projects – articles, blog posts, presentations – get their own folder. Each time I reference a journal article for the project, the reference gets copied into the project folder. When the project is complete, I simply print a bibliography of all the references used. It works great. Fortunately, Zotero has a nice desktop application with great functionality and it’s free. Unfortunately, Zotero’s web app is an abomination. I don’t know how it’s possible to have such a great little desktop app and completely ignore “the web”. Of all the things that have given me trouble, this is the biggest. I don’t know if I can get past this one. The inability to use Zotero on the web has had a negative impact on the way I work.

Notepad – Yep, one of the simplest applications on the planet. I use it a lot. Sometimes I’ll use it for nothing more than a quick, disposable note. Other times I’ll use it as a quick and dirty way to eliminate all formatting associated with a bit of text, i.e. copy the text and paste it into notepad; this is a great trick when I’ve tried some crazy formatting and can’t seem to back out. Notepad is always open on my Windows 10 desktop. While there are lots of note-taking apps for Chrome, I haven’t found an equivalent. For the time being, I’m using Google Keep. It’s not the same, but it works.

In many ways, the Acer Chromebook 14 meets my expectations: it has a solid build, it has a nice 14-inch screen, good keyboard, the integration with my Android smartphone (Samsung Note 5) and Google Home is nice, it has ridiculously good battery life — I’m getting ten plus hours per charge — and it’s nice to look at. In other ways, the Acer Chromebook 14 has failed to meet my expectations: lack of a backlit keyboard, Android apps not yet available even though the device itself was introduced over a year ago, and lack of solid web-based apps. In all fairness, that last item isn’t the Chromebook’s fault, but it makes a big difference.

Overall, I find that the Acer Chromebook 14 is a great machine. I’m sure it could be a Windows 10 laptop replacement for someone, but probably not for me. At the moment, I’m still on the fence about keeping it. At sub $300, it might be worth keeping around. But then again, a new Windows 10 tablet would be nice.

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EHRs are an untapped, but almost impossible to use, health resource

We’re all familiar with the promise of “big data” in healthcare. Crud, I’m a huge fan of using data. I think the amount of information inside an EHR has the potential to do a lot of wonderful things, not only for healthcare in general but specifically for a pharmacist. How many kinetic consults have been done by hand, tracked manually, and refined by voodoo magic? Thousands, I can assure you. The number of things pharmacists still do manually is staggering. “Monitoring” should no longer involve rummaging through charts — electronic or otherwise — looking for tidbits of information that need to be “fixed”. The days of dosing medications like vancomycin, warfarin, phenytoin, and aminoglycosides — just to name a few — should be long gone. We can contemplate building a Hyperloop, but we can’t figure out how to get someone’s INR to a therapeutic level within five days? Seriously, think about that for a second.

FierceHealthcare: “For public health agencies, tapping into EHR data could augment the costly and time-consuming process of surveys….Data analytics has emerged as a key tool for providers to target high-risk populations with chronic conditions, although some have argued that health IT systems are still ill-equipped to adequately manage population health.” There’s the crux of the matter, data is valuable, but it’s tough to get. I’ve only recently started to request specific data from the EHR to look at some things I find interesting. Unfortunately, I’ve run into roadblocks. Apparently, the data inside an EHR — at least inside this particular EHR — isn’t easy to retrieve. At least that’s what I’ve been told. How hard can it be? Dude, just dump the raw data somewhere and I’ll build the queries myself. Again, apparently not that easy. 

In a nutshell, all patient data, from demographics and notes to labs and medication use should be easily accessible to anyone with appropriate credentials, i.e. a pharmacist that works for the hospital where an EHR is used, for example. Only when we, as healthcare professionals, can access data at will, and use that data to answer questions, will EHRs become valuable to patient care. At present, EHRs are full of potentially valuable information that no one can get. It’s like having a savings account that only allows deposits, no withdrawals. The balance might look great, but what do you do when you need a little money and the bank says “sorry, there’s no way to take your money out”? Throw in the fact that EHRs are a usability nightmare and you realize that we have a long way to go.

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A cautionary tale for healthcare. A lesson for pharmacy.

A couple of days ago I read an interesting piece by John Halamka over at healthsystemCIO.com. In it, Halamka shares two stories about purchasing parts for some projects. One part required a lot of legwork and took a month to secure. The other required a quick Amazon search and less that 24 hours to obtain.

It’s clear [the people running the company have] been asleep since 1985. When it comes time to replace the windows in my buildings, I would never consider Marvin Windows products, since it’s clear they care more about preserving an ancient business model and less about their customers’ modern expectations and experiences”. I feel that this accurately describes today’s pharmacy model.

The pharmacy practice I returned to after nearly a 10-year absence appears to have been frozen in time. Yes, things have changed here and there, like the introduction of EHRs, but the distribution model feels the same as the one I left around 2006. It’s a model that relies heavily on humans to perform manual tasks, which isn’t terrible per se. Unlike others, Amazon, for example, there has been a failure in pharmacy to introduce and integrate automation and technology into the distribution process. While pharmacy continues to rely heavily on people and very little technology, Amazon has designed a system that uses people plus strategically chosen technology to improve efficiency and accuracy.

In today’s pharmacy model, medication orders are manually pulled, stocked and counted. Manual “double” and “triple” checks are used in place of simple technologies like barcode scanning and robotics; often leading to slips and lapses. Medications are frequently lost due to the inability to accurately track them once they leave the pharmacy. This in turn results in medications being re-dispensed and often given late. Stickers identifying medications as high-risk, high-alert, STAT, sound-alike-look-alike, “note dose”, “rectal use only”, “neuromuscular blocker”, and a slew of others, decorate the shelves turning them into a Jackson Pollock painting.  Buyers still walk the shelves and manually evaluate stock levels. Paper logs are filled with information that is often redundant and available elsewhere in digital form. Legacy software sits on desktop computers while the cloud begs to be used. “Mobile pharmacy” means the pharmacist is walking around. If you didn’t know better, you’d think I was joking. I’m not.

In the article, Halamka states that “The lesson learned is that in the near future, healthcare organizations that offer an Amazon approach will displace this [sic] which do not.” I wonder if this applies to the pharmacy as well as healthcare organizations. I think not. Time has shown that pharmacy is an often forgotten part of the healthcare system. Pharmacists get promoted to move up and out of the pharmacy. No one ever moves “down” into the pharmacy. As the saying goes, it’s a good place to be from.

Halamka describes the progressive nature of Beth Israel Deaconess Medical Center (BIDMC). It’s impressive, to be sure. But even so, I’ve never heard of the BIDMC pharmacy. I’m sure it’s a fine pharmacy, but it’s never come up in any conversation or discussion of “the best” or the “most progressive”. I hear about BIDMC and Halamka all the time. Why not the pharmacy? Is the department as forward thinking as the rest of BIDMC? I don’t know. Perhaps someday I’ll find out.

Companies that provide technology to pharmacies are partly to blame. Their products often lack proper functionality and are woefully inadequate for the tasks at hand. With that said, it’s unfair to hold them responsible for our lack of progress. After all, pharmacy administrators are cheapskates, unless of course, they can make a lot of money – 340B, specialty pharmacy, etc – and then they’re all over it. But for the average, desperately needed technology, those in charge are unwilling to invest even when the technology has demonstrated improved patient safety and workflow.

It’s difficult for me to take a Pharmacy Director seriously when they say “we don’t have the money” only to take a stroll through the pharmacy and see inefficiency compounded with bloated drug budgets and out-of-control overtime numbers. Fixing even one of those would free up enough money to implement any number of additional technologies.

More often than not, I find that I’m speaking to myself when attempting to engage others in this conversation. Most want to discuss “clinical pharmacy” and “patient safety”(1) initiatives, all the while missing the bigger picture in favor of the minutia. It’s this clear lack of strong leadership and forward thinking(2) that will continue to plague pharmacy for the foreseeable future.

In the best interest of healthcare systems everywhere, I think it’s time to turn all pharmacy operations over to Amazon. I jest, but only a little.

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  • Strange that many pharmacists don’t see the connection between using automation and technology and patient safety. True story.
  • There’s a whole nother blog post in there.

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Thoughts on my time with DoseEdge Pharmacy Workflow Manager 

Yesterday, I had a great opportunity to spend the day using DoseEdge in its native environment. That is to say, I staffed at a facility that was using DoseEdge in its cleanroom to prepare CSPs, including patient-specific products as well as stock bags, TPNs, etc. I’ve used DoseEdge for brief periods in the past. I’ve also spent time with the engineers that have worked on the product, product managers, sales people, marketing folks, and various other Baxter employees at conferences like ASHP midyear. But, this is only the second time that I have worked an entire  “staff pharmacist” shift using the product. And as one might imagine, using a system in its native environment can often provide a new perspective.

DoseEdge System at Boston Children’s Hospital

I’ve written about DoseEdge, and systems like it, extensively on this site over the years.  A quick search of jerryfahrni.com revealed several articles mentioning DoseEdge, dating back to 2010. I’ve also written about DoseEdge and similar products extensively elsewhere.

With over 300 installs in the U.S., DoseEdge is one of the most popular IV workflow management systems on the market and is still the most widely implemented product of its kind in the U.S. It’s a very good system, certainly in my top five. There are several things that I really like about the system, such as how it controls labels, its ability to track partial vials, and the fact that it talks. Seriously, it speaks to the user. Pretty cool.

However, there’s always room for improvement. For example, after using the system, I found that I don’t really care for the user interface (UI). I found it to be rather unintuitive and a bit clumsy. The UI is stuck somewhere between a legacy system and a modern web-based system. It’s not good. Too many clicks, things in weird places, naming conventions that simply don’t make sense in my mind, just to name a few. With that said, it’s still quite usable, and honestly, it’s likely as good as any other UI on any other product that I’ve used in the pharmacy.

The other thing that hit me yesterday was just how terrible the process of using images is to verify the accuracy of compounded products. I don’t care for it. As good as the images are – and they’re quite good in DoseEdge – there are still shadows in strange places that make reading syringe volumes difficult at times. This is especially true for small volumes. There were times yesterday when I simply made educated guesses to the exact volume and assumed that the volume was accurate, as I couldn’t quite see the exact location of the plunger. Don’t get me wrong, this is still way better than the syringe-pullback method, but image-assisted verification isn’t optimal. I would have liked to have had the gravimetric option available to me yesterday. DoseEgde offers gravimetrics, although it isn’t widely used.

So, good system, but not perfect. Better than the manual process, but room for improvement. Imaging better than pullback, but not great.

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Does charge-on-chart hurt or help medication chain of custody?

Historically, hospital pharmacies have used a charge-on-dispense (COD) model for medications. The model charges the patient for a medication when it is dispensed from the pharmacy and credits the medication if it’s returned to the pharmacy unused. Simple, but labor-intensive. The model itself has been around for a long time.

The introduction of electronic health records (EHRs) and electronic medication administration records (eMARs) has pushed the COD model aside in favor of the charge-on-chart (COC) model; sometimes referred to as “charge on administration” (COA). In the COC model, the patient isn’t charged for a medication when it is dispensed from the pharmacy because the charge is captured when the medication is scanned by the nurse and administered to the patient. When the nurse scans the medication, the information is captured by the eMAR and charted, hence the name. There are several benefits to this model, including no need for the pharmacy to credit medications that go unused. Unused medications are simply returned to the pharmacy and folded back into the inventory.

Put simply, the COC model eliminates the need for pharmacies to charge and credit medications as they are dispensed and returned to the pharmacy. But here’s a little untoward side effect of the COC model, it eliminates much of the pharmacy audit trail for medication movement into and out of the pharmacy.

The old COD model wasn’t perfect, and there were plenty of discrepancies, but I wonder if the COC model has created even less transparency regarding inventory reconciliation and the movement of medications throughout the hospital.

Inventory management systems like AutoPharm from Talyst and Pyxis Pharmogistics from Carefusion should, in theory, give pharmacies real-time inventory numbers. But the promise of these systems has fallen short. Both utilize barcode scanning to track inventory, which unfortunately requires humans to be diligent when scanning items in and out of inventory. Human laziness usually prevails, and numbers are frequently inaccurate.

Medication tracking systems are available from a couple of companies, but also utilize barcode scanning, thus fall prey to the same weakness mentioned above. These systems also fall short when following medications throughout the medication distribution process as they typically stop as soon as the medication is delivered to the nursing unit, i.e. they don’t track the return of the medication.

Track and trace regulation, which will require serialized barcodes and tracking from manufacturer to patient, could potentially help with this issue. However, that process has the same weaknesses as those mentioned above, namely human intervention.

RFID technology would surely be better than barcode scanning, except that RFID tags are too costly for use on all medications and drug manufacturers are nowhere near ready to do anything like this.

Currently, the only medications that receive enough scrutiny in a pharmacy to determine location and quantity at any given moment are controlled substances, i.e. morphine, fentanyl, oxycodone, and so on. And this falls short on some level once the medication leaves direct oversight of the pharmacy.*

It’s interesting to think that as much time as we spend managing inventory in a hospital pharmacy, we still have a long way to go.

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*This includes leaving the pharmacy itself as well as storage devices like automated dispensing cabinets (ADC). When a medication leaves the ADC we assume it has been administered to the patient once it has been charted. We cannot confirm this, however. For all we know, the healthcare provider that removed the medication and documented the administration, simply put it in their pocket and walked out with it. You never know for certain.

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